Sample Claim Forms

8/2/2019 Sample Claim Forms

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National Hearing Care


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This is a triplicate form that can be used to hand write the claim forms

when the computers are unavailable. There is usually some pads of theseavailable in the clinics.

OHS Claim For Payment Form

Notes:....


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Provider Name, Voucher Number and Client number must be entered on all claim forms.

All Assessments, Maintenance and Aid Adjustments to be entered in these fields.

Fitting Item, Review = Date of Service etc. entered in this field.

Device Code, date offitting etc. to be enteredhere.

3FAHL entered which is obtainedat the Assessment. Balance of all 3 fields in

bottom box.

Notes:

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The clients name must be entered, client sign and dated. The signature date must not be beforethe date of service for any item.

All boxes must be completed for any claim. The top box needs toreflect the $ box eg. yes $36.75 or no $NIL.

Boxes always marked the same

Total Cost of Program = Client fee forMaintenance and client fee for devices.

Service Provider no:020103B

ABN Number: 68200763765

No=tax exempt, Yes= GST registered.

Consulting Audiologists name must be entered and signed and dated by said person. Date mustbe after client date and date of service.

All boxes must be completed for all claims

Notes:....


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Claim Item 600

This client has a New Voucher and has attended for an Assessment Appointment.

The Date of Service is the Assessment Date and the client is not required to paymaintenance at the Assessment.

Assessment Item 600

Notes:...

Sign all Claim Forms with a Blue Biro


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Assessment Item 800

Claim Item 800

This client has a Return Voucher and has attended for an Assessment Appointment.

The Date of Service is the Assessment Date and the client is not required to paymaintenance at the Assessment.

Notes:...



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Claim Items 600 & 610

This client has a New Voucher and has attended for an Assessment Appointment. TheDate of Service is the Assessment Date and the client is not required to pay maintenanceat the Assessment.The Audiologist also performed extra service during to appointment to warrant the claimingof the 810 item which represents Audiological Case Management.

Assessment 600 & 610

Notes:...



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Assessment 800 & 810


This client has a Return Voucher and has attended for an Assessment Appointment.The Date of Service is the Assessment Date and the client is not required to paymaintenance at the Assessment.

The Audiologist also performed extra service during to appointment to warrant theclaiming of the 810 item which represents Audiological Case Management.

Notes:...



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Claiming Item 630

This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with onehearing aid (device) and the date of service was the review date. The client has electedto pay extra money to Top Up their device and this is mentioned in the Cost to clientsection.

The client has also paid the maintenance fee and the Total Cost to client totals themaintenance fee together with the client cost of the device.

Fitting & Review 630

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Claim Item 640

This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with twohearing aids (devices) and the date of service was the review date.

The client has also paid the maintenance fee and the Total Cost to client shows themaintenance fee only.

Fitting and Review 640


Notes:....


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Fitting and Review 640 & 777


This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with twohearing aids (devices) and the date of service was the review date. The client haselected to pay extra money to Top Up their device and this is mentioned in the Cost toclient section.

The client would normally pay maintenance however as the client is DVA exempt (thiswould be stated on the voucher) the item 777 is also claimed.


Notes:....


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Claim Item 650

This client has a new voucher and attended for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with one hearingaid (device) and the date of service was the review date.

The client has elected not to take up the maintenance agreement and therefore willpurchase all batteries and pay for all service and repairs done to the device. The clientmay take up maintenance 12 months from the fitting date.


Notes:....



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Claim Item 660

This client has a new voucher and attend for a fitting and review appointment. Theclient has never been fitted before with hearing aids. The client was fitted with onehearing aid (device) and the date of service was the review date.

The client has elected not to take up the maintenance agreement and therefore willpurchase all batteries and pay for all service and repairs done to the devices. Theclient may take up maintenance 12 months from the fitting date.

Notes:....



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Claim Item 820

This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device.

The client is already covered for maintenance and therefore not maintenance is requiredat this time.


Notes:....



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Claim Item 830

This client has a return voucher and has previously been fitted with hearing aids.The client is currently been fitted with two new devices.

The client is already covered for maintenance and therefore no maintenance isrequired at this time.

Notes:....



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Item 820 & 700

This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device. The client has elected to pay extra money toTop Up their device and this is mentioned in the Cost to client section

The client is due to pay maintenance again and therefore the claim of 700 is made and theclient is required to pay the at this time.

As the client has paid the maintenance fee the Total Cost to client totals the maintenancefee together with the client cost of the device.


Notes:....



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Item 830 & 710

This client has a return voucher and has previously been fitted with hearing aids. Theclient is currently been fitted with two new devices.

The client is due to renew their maintenance again and therefore the claim of 710 ismade and the client is required to pay the at this time.

As the client has paid the maintenance fee the Total Cost to client totals themaintenance fee together with the client cost of the device.

Notes:....



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Claim Items 820, 700 & 777

This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device. The client has elected to pay extra moneyto Top Up their device and this is mentioned in the Cost to client section

The client is due to pay maintenance again and therefore the claim of 700 is made.However the client is DVA exempt (this would be stated on the voucher) and thereforethe item 777 is also claimed.

The Total Cost to client totals the maintenance fee together with the client cost of thedevice.

Fitting and Review 820, 700 & 777

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Claim Items 830, 710 & 777

This client has a return voucher and has previously been fitted with hearing aid/s. Theclient is currently been fitted with one device. The client has elected to pay extra moneyto Top Up their device and this is mentioned in the Cost to client section

The client is due to pay maintenance again and therefore the claim of 700 is made.However the client is DVA exempt (this would be stated on the voucher) and thereforethe item 777 is also claimed.

The Total Cost to client totals the maintenance fee together with the client cost of thedevice.

Fitting and Review 830, 710 & 777

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Claim Item 840

This client has previously been fitted with hearing aid/s during the last 5 years and haseither lost one or has damaged one beyond repair. An OHS Statutory Declaration isrequired to be completed for file record. The client is currently being fitted with onedevice.

A replacement fee of $30.00 is required to be paid by the client.

The client is already covered for maintenance and therefore no maintenance fee isrequired.


Notes:....



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Claim Item 850

This client has previously been fitted with hearing aid/s during the last 5 years and hashad either lost both or both are damaged beyond repair. An OHS Statutory Declarationis required to be completed for file record. The client is being re-fitted with two devices.


The client has elected to pay extra money to Top Up their device and this is mentionedin the Cost to client section. The client is already covered for maintenance andtherefore no maintenance fee is required.

Notes:....



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Maintenance Renewal 700

Claim Item 700

This client has previously been fitted with one hearing aid, the clientmaintenance is due to be renewed. This is due on the anniversary of the clientfitting date.

Notes:....



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Claim Item 710

This client has previously been fitted with two hearing aids, the client maintenance isdue to be renewed. This is due on the anniversary of the client fitting date.

Maintenance Renewal 710

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Maintenance Renewal Items 700 & 777


This client has previously been fitted with one hearing aid. The clients maintenance isdue to be renewed however the as client is DVA exempt (this would be stated on thevoucher) the item 777 is also claimed.

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This client has previously been fitted with two hearing aids. The clients maintenance isdue to be renewed however as the client is DVA exempt (this would be stated on thevoucher) the item 777 is also claimed.

Maintenance Renewal Items 710 & 777

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Claim Item 711

This client has relocated to NHC with a relocation letter from OHS. The client already hasone hearing aid form another provider and is already covered for maintenance. Thereforeitem 711 is claimed to take over the maintenance agreement. The client is NOT requiredto pay the fee again for another 12 months from the date this claim is made.

Relocating Maintenance 711

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Relocating Maintenance 722

Claim Item 722

This client has relocated to NHC with a relocation letter from OHS. The client alreadyhas two hearing aids form another provider and is already covered for maintenance.Therefore item 722 is claimed to take over the maintenance agreement. The client isNOT required to pay the fee again for another 12 months from the date this claim ismade.

Notes:....



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This client is an exempt client who has previously been fitted with hearing aid/s duringthe last 5 years and one has been either lost or damaged beyond repair. An OHSStatutory Declaration is required to be completed for file record. The client is currentlybeen re-fitted with two devices.


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This client is an exempt client who has previously been fitted with hearing aid/s during

the last 5 years and both have either been lost or damaged beyond repair. An OHSStatutory Declaration is required to be completed for file record. The client is currentlybeen re-fitted with two devices.



Notes:....



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Claim Item 930

The client attended for an Aid Adjustment appointment and currently has one hearing aid.An aid adjustment is where the client is experiencing less than optional satisfaction withtheir hearing aid and where it is more than 12 months from the date of initial fitting.

This claim may be made every 24 months if necessary. A new voucher is not required.

Aid Adjustment 930

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Aid Adjustment 940Claim Item 940

The client attended for an Aid Adjustment appointment and currently has two hearing

aids. An aid adjustment is where the client is experiencing less than optionalsatisfaction with their hearing aid and where it is more than 12 months from the date ofinitial fitting. As the client has two aids, a binaural aid adjustment item is claimed, evenif only one aid is adjusted.

This claim may be made every 24 months if necessary. A new voucher is not required.

Notes:

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Claim Item 760

This client has a current voucher (either new or return) and has attended a fitting andreview appointment. The client has previously been fitted with one device on the right earand is now being fitted with a device for left ear.

The client is still covered under a maintenance agreement with the right device and thenew aid will join that agreement.


Notes:....



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Claim Item 770

This client has a current voucher (either new or return) and has attended a fitting andreview appointment. The client has previously been fitted with one device on the right earand is now being fitted with a device for left ear.

The client is does not wish to have the aid covered by maintenance

Notes:....



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Privately purchased aids 790

Items 790 (for a monaural aid) and 791(for binaural aids) can be claimed for a clientwho has purchased their aid/s privately and then becomes eligible for the pension.

The client requires an OHS Voucher and an assessment prior to this claim beingmade. The item should be claimed on the same claim form as the assessment.

The audiologist MUSTfind the aids to be in goodworking order. OHSexpect the aids to last forat least two years. Theclient pays maintenance

fee of $36.75.It is important to notethe date of service forthe 790/791 will becomethe fit date/s against thevoucher thus making itfully serviced.

If an Item 790 or 791 has


Notes:....

and a refit is being

contemplated a RETURNVoucher will be requiredtogether with the normalrefit application to HO.Contracts will be either 820or 830.


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Privately purchased aids 791

Items 790 (for a monaural aid) and 791(for binaural aids) can be claimed for a client

who has purchased their aid/s privately and then becomes eligible for the pension.The client requires an OHS Voucher and an assessment prior to this claim beingmade. The item should be claimed on the same claim form as the assessment.

The audiologist MUST find theaids to be in good working order.OHS expect the aids to last for atleast two years. The client paysmaintenance fee of $36.75.

It is important to note the dateof service for the 790/791 willbecome the fit date/s againstthe voucher thus making itfully serviced.

If an Item 790 or 791 has beenclaimed previously and a refit isbein contemplated a RETURN


Notes:....

Voucher will be required together

with the normal refit application toHO. Contracts will be either 820or 830.


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Provision of a Spare Aid 960

This item can be claimed for clients who have been fitted monaurally, have only

one aidable ear and do not have access to their audiologist. The client would bedisadvantaged if their aid was lost/damaged or needed to be sent away to berepaired. Approval must be obtained from OHS prior to fitting the aid. An item630, 650 or 820 must have been previously lodged.

Sign all Claim Forms with a Blue BiroNotes:....

Documents

Sample Claim Forms